3-minute case study: Harm reduction, then recovery

By Lia Novotny | March 1, 2018

image of a tent with opioids spilling out, outside of a SPOT treatment center

What innovations drive success in healthcare? Here's a tactic from a leading community health partner.

The problem

Addiction is a critical issue for homeless people in Boston, but as Boston Health Care for the Homeless Program (BHCHP) suspected, the people who need help the most aren't asking for it.

In its efforts to address a rising death toll in the homeless population, BHCHP launched initiative after initiative, but only those who were actively trying to get sober requested help. 

Otherwise, patients would come in at risk of an overdose, and staff would have to call 911. Patients would either be taken to an emergency department or be given a large dose of naloxone, sending them into immediate withdrawal. And patients in full withdrawal are too preoccupied with their physical condition to have a conversation about recovery or treatment.

By 2012, a mortality study conducted by BHCHP revealed that overdoses had become the leading cause of death among the homeless.

The solution

In April of 2016, BHCHP opened the Supportive Place for Observation and Treatment (SPOT): A dedicated room in its ambulatory clinic where up to 10 people at immediate risk of overdose can be monitored. The goal is simple: to give homeless people of Boston another shot at life, and therefore recovery.

“This is not necessarily directed at people who are trying to get sober. This is a treatment for people who are actively using [opioids or other drugs]. We really want to engage people who are at the highest risk of dying, and help them to survive today," says Gabriel Wishik, M.D., MPH, site medical director at BHCHP's clinic.

As the medical community moves to treat substance use disorder as a chronic illness, it's becoming clear that patients need treatment at all stages of the disease. BHCHP designed SPOT to reduce the barriers to care and meet patients where they are right now, whether they come in on their own or they're brought in for treatment.

Interventions such as oxygen or small doses of naloxone are carefully administered by a staff of registered nurses specializing in addiction — with the support of case managers and as-needed physician specialists.

Care plans can include referral to rehab, but more often, they're focused on harm reduction — how can patients be safe today and tomorrow? Often, nurses council patients on how to avoid particularly dangerous multidrug cocktails.

These interventions take place in a comfortable, safe space designed to be free of judgment. Wishik says, “There's something profound about just saying, 'We're here for you,' and nothing more. We don't require you to change today."

The outcome

Seats were full almost from the day SPOT opened its doors. As of early 2017, the program had seen 500 individuals in 3,850 separate encounters. To date, there has not been a single death at SPOT, according to Wishik. 

The organization is gathering and aggregating data on what overdose looks like today in terms of blood pressure, respiratory rates, and other vital signs. And they are identifying the most effective interventions, which is especially valuable with respect to new drugs or drug cocktails.

At SPOT, nurses and harm reduction specialists engage patients to build meaningful relationships with a high-risk, hard-to-reach cohort. About 10 percent of the time, that support moves the patient straight into recovery — but the more important goal is giving every patient another day. 

As Wishik says, “There's a saying out there: Dead people can't recover. We want people to get to recovery – eventually, if that's what they want. [SPOT] is designed to help them get there."

Lia Novotny is a frequent contributor to athenaInsight.

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